The marine industry continues to be concerned with problems involving the effectiveness of bridge teams in pilotage waters. The International Maritime Organization (IMO) put forward measures that will lead to higher training standards and greater safety. One such measure was BRM training and implementation. Occurrences involving vessels operating in pilotage waters continue to draw the attention of the Board. The analysis of what happened in this occurrence, and why, is presented within the framework of group dynamics, issues related to shipboard navigational operations, technological advance, and pilotage.2.0 Analysis The marine industry continues to be concerned with problems involving the effectiveness of bridge teams in pilotage waters. The International Maritime Organization (IMO) put forward measures that will lead to higher training standards and greater safety. One such measure was BRM training and implementation. Occurrences involving vessels operating in pilotage waters continue to draw the attention of the Board. The analysis of what happened in this occurrence, and why, is presented within the framework of group dynamics, issues related to shipboard navigational operations, technological advance, and pilotage. 2.1 Group Dynamics The NorwegianSky is equipped with state-of-the-art navigation equipment. From the start of the voyage, an ongoing exchange of information was established among the navigation personnel and between senior staff and the pilots. Centralized bridge functions of the IBS on board the NorwegianSkywere conducive to this open and ongoing information exchange. The excellent rapport between navigation personnel and the pilots during the voyage downriver pointed to a good working atmosphere. During their voyage briefing, the pilots were informed by senior staff that they wished to carry out whale-watching, at the discretion of the master. All agreed that it was feasible, given the fact that cruise liners regularly carry out whale-watching activities on the St.Lawrence River. A good example was the use of limited helm off CapTrinit. Given the characteristics of the rudder, the master advised the pilot to use a small angle of helm to execute the turn before heading back down the Saguenay River. The pilot readily accepted the recommendation. The open exchange of information continued when the cruise director requested that the period of whale-watching be extended. The decision to execute the manoeuvre was made jointly by the master and the pilot, based on the facts that it would not interfere with the vessel's schedule and that it would lead to passenger satisfaction. At this point, information was shared among key decision makers, but it was limited to the schedule of the vessel. In so doing, one of the key elements essential for making this decision - that the turn could be completed safely - remained unaddressed. During the turnaround manoeuvre, the pilot transmitted orders to the helmsman and, unless specifically advised by the pilot to select a vessel speed, the master controlled engine speed and pitch levers. There appears to have been an implied agreement between the master and the pilot as to their respective actions. However, contrary to normal bridge practice, engine movements executed by the master were not communicated to the bridge team. Consequently, communication on the bridge was incomplete: all pertinent information that could affect navigation was not shared. When the cadet informed the master that the vessel was nearing the banks off leRouge, the information raised concern among team members. The master shared this concern with the pilot, who assured the master that all was under control. However, the exchange of information was elementary, and conflict resolution mechanisms were not used. The pilot concentrated his attention on navigating by radar. Throughout this tense period, the pilot does not remember having a detailed conversation with the master. Such being the case, the pilot more likely acknowledged the request of the master without giving it the importance required and turned a deaf ear to the information concerning the manoeuvring characteristics transmitted to him. The pilot took it upon himself to assess the situation and complete the turn, based on his assessment. Although he could not confirm the exact position of the vessel relative to the banks, the pilot insisted on maintaining hard-a-port helm. When the pilot elected not to take the advice of the master, who knew the ship's handling characteristics best, the master did not countermand the pilot's order of hard-a-port helm. The good group dynamics that were present during the routine voyage down river gradually degraded after the vessel deviated from its planned route. Reduction in the team's cohesiveness coincided with the development of a rapidly deteriorating situation. Technical skills acquired by bridge team members could have efficiently complemented each other. The pilot had gained local knowledge through a long career on the river. Navigation personnel had acquired a good understanding of the ship's handling characteristics during sea trials and had attended an INS awareness course on working with and operating the navigation equipment. With increasing use of INS in an IBS environment, sufficient training and experience is necessary to take full advantage of this new technology. It takes time to effectively apply such technology on vessels. Until training to provide an adequate level of proficiency is in place, full participation from all team members on ships may be difficult to attain. By law, pilots are technical advisors to a ship's personnel in most maritime countries, although ship's personnel generally consider pilots to be in total control of the vessel. As a result, a bridge team hierarchy can develop where the pilot is perceived to have greater authority than the master, who is, in fact, in command of the vessel. Historically, pilots have not shared navigational or manoeuvring information with ship's personnel, nor have they been accustomed to receiving advice from the ship's complement. These factors tend to degrade team cohesiveness and undermine the concept of BRM. Therefore, when the pilot insisted on using hard-over helm, navigation personnel (who were accustomed to executing the orders of the pilot) readily acquiesced and elected to follow the order. Formalized BRM is being implemented successfully on ships. Training focuses on bridge team-building and communication. During normal operations, the bridge team applying BRM is dynamic: navigation officers and pilots share the work and provide checks and balances. However, training of navigation officers and pilots is usually conducted separately. As a result, bridge teams may not function as effectively when in the presence of a pilot, and a pilot may experience difficulties integrating with the bridge team. The effect of this lack of integration may not manifest itself until times of increased stress, such as during an emergency situation. The ability of this team to work together was not put to the test until the cadet brought to the attention of the master the fact that the vessel was rapidly approaching the shoal - the start of a developing emergency situation. As the situation deteriorated, the team acquiesced to the pilot, breaking down the team's cohesiveness and effectively converting the team to a single-person operation. Recognizing this shortcoming, some marine training institutions engage the services of a pilot to better simulate reality and highlight the dynamics or interaction in the relationship between a pilot and a ship's navigation personnel. 2.2 Shipboard Navigational Operations 2.2.1 Factors Influencing Decision Making Passenger vessels commonly extend whale-watching activities. However, this change often involves some level of improvisation on the part of the bridge team, and improvisation increases risk. At approximately 1153, when the request was made to extend whale-watching activities, the weather was clear. The St.Lawrence River is very wide at the mouth of the Saguenay River, giving rise to a false perspective of a large manoeuvring space. The north shore was visible some five nm away, and le Rouge and the Haut-fond Prince lighthouse were more than 2nm off. These distances, together with the vessel's exceptional manoeuvring capabilities, might have provided a false sense of security to the bridge team and could account for the minimal planning of the manoeuvre. Although the shoal water between the vessel and le Rouge was close (approximately six cables) when the decision was made to extend whale-watching, there was sufficient room for the turnaround manoeuvre to be completed safely. Positioned north of the Bancs de l'leRouge at 1153, the NorwegianSky was barely making way as it lay across the southerly setting flood tide. At a drift speed of two knots, the current would drive the vessel ashore in about 18minutes. Because the vessel was about to turn in the same direction as the current, the effect of the current was amplified. In situations where there is an increased risk, the navigation team must rely on close monitoring of the vessel's progress using all available means. 2.2.2 Limitations of the Navigation Practices Used The pilot initially observed the radar target of Haut-fond Prince light on the inside edge of the two nm range ring. This cue permitted the vessel to clear the western edge of the Bancs de l'leRouge at buoyK55. The selected method had only a one-dimension accuracy because it did not provide information as to the vessel's drift on the north-south axis. The ECS revealed that the vessel did progress southwardly beyond the two nm limit and, eventually, southeast onto the shoal. The OOW and the cadet, who plotted the vessel's position by radar, placed their last noon position some 3.8cables off the northwest edge of the Bancs de l'le Rouge. Although valuable under normal circumstances, position plotting provides historical information only. Because the vessel did not maintain a constant heading throughout the manoeuvre, this technique did not allow for an accurate projection of the vessel's position beyond1200. The master used visual observation as a primary source of information. Since the Pointe Noire beacons could not be seen at noon from the central workstation, buoysK51 andK55 became the most prominent navigation aids forward of the beam. As the imaginary line between the two buoys got closer, the limit of approach to the shoal became more difficult to visualize and thus determine. At this time, the pilot estimated the vessel to be four cables downriver of buoyK55. The vessel, however, was only some 2.5cables off the buoy. In other words, the pilot underestimated the manoeuvring room required to carry out the contemplated turnaround manoeuvre using helm only. By deviating from the normal route, the pilots were no longer using their usual courses to navigate. Notwithstanding the fact that they had a thorough knowledge of the marine topography of the St.Lawrence river, they no longer had the same level of preplanned cues essential to orient themselves and to maintain an equivalent level of security as that required on the normal route. 2.2.3 Technological Changes The marine industry is undergoing an evolution in automation similar to other transportation industries. New technology affects not only bridge equipment and layout but also shipboard operation. For navigation to be conducted safely, the sheer volume and diversity of information on a bridge must be effectively managed. Automation, adequately designed and used by properly trained personnel, has the potential to improve operational efficiency and safety.16 2.2.4 Radar Techniques Although manual position plotting is an adequate means to maintain situational awareness when navigating in coastal waters, it does not offer real-time position information when proceeding in a restricted waterway. No matter how frequent or how fast the plotting is carried out, collated information will be historical. Using this method, a vessel's progress can only be estimated, particularly when the vessel is constantly changing heading. Various techniques that could have provided a better appreciation of the vessel's movement were available to the bridge team, including the use of true motion and parallel indexing techniques. These techniques provide real-time position of the vessel in relation to identified hazards depicted on the radar screen and could have been used to complement conventional position plotting. For example, electronic bearing lines could have indicated a safe distance off the Bancs de l'leRouge. In restricted waterways, where prompt and effective action is essential to address the dynamic nature of navigation, use of advanced radar techniques would enhance the navigator's ability to better maintain situational awareness. 2.2.5 Effective Use of Resources The NorwegianSkyhad proceeded efficiently and safely toward the pilot station while the pilots put into practice the voyage plan they had learned and perfected throughout their careers. Deterioration in the cohesiveness of the team coincided with the rapidly developing emergency as the vessel deviated from the plan. When the master expressed concern to the pilot that the vessel was coming close to the shoal, he deduced that the situation was under control. Further, when the pilot ordered hard-a-port helm and an increase in engine speed, the master cautioned the pilot that hard-over helm would swing the vessel's stern further toward the shoal. However, the pilot insisted on hard-over helm. By now, the focus had shifted to the use of helm only, and other options, such as going astern on the starboard engine and/or using thrusters, were not used to extricate the vessel from the situation. Because ECS and radar were not used to advantage, decision-making team members were deprived of complete, real-time information that was essential to make an informed decision in a rapidly developing situation. In summary, the bridge team did not use all available means to accurately determine the vessel's position and/or did not use information at its disposal to accurately assess the developing situation or the success of the manoeuvre. As a last-minute change from routine, the manoeuvre was improvised. Good watchkeeping practices (properly monitoring and cross-checking the progress of the vessel) were not adhered to, and situational awareness in the final stages of the manoeuvre was lost. 2.2.6 Lack of INS Experience To meet the functional requirements of modern navigation equipment, IBS and INS have been introduced to the maritime industry to respectively offer a centralized access to sources of navigation information and an interface between navigation components. New technology is developing rapidly but has not spread throughout the industry. As a result, bridge teams have limited experience on these systems and do not make optimal use of them. Because navigation personnel had received INS training, they used the network radar system to share information. Position plotting carried out at the communication workstation could be observed by the master at the central workstation. The INS was also designed to allow a team member to work independently from the rest of the team. Because the workstations were equipped with two monitors, one could be used for radar and the other could represent the overlay. This would have permitted the pilot and the master to observe both presentations. The interface between different navigation components made it possible to compare radar information with the ECS. However, the chart provider used non-official data to produce the electronic navigation chart (ENC) which was at variance with the CHS official chart data. Consequently, the radar presentation could not precisely match the ECS presentation of shoreline features. Nonetheless, when one was overlaid on the other, the position of the vessel relative to geographical information would have enhanced the pilot's and the master's ability to maintain situational awareness. In this occurrence, only the radar was used and the integrated radar system was not used to advantage. The level of ECS monitoring and the level of INS use point to poor management of resources. There is a need to establish procedures or conventions to effectively monitor all automated navigation equipment. Connecting navigation equipment to a network will eventually facilitate teamwork among bridge team members, including pilots, particularly when all team members have acquired sufficient knowledge and experience to use the network system. 2.3 Effectiveness of INS Training IMO working committees have highlighted the close relationship between INS and IBS and have emphasized the need to examine this relationship thoroughly when considering development of new performance standards. The crew and the pilot had received BRM training. Furthermore, the pilot had attended simulated electronic navigation (SEN) II training and, the master, an equivalent course. In this instance, neither the pilot nor the master elected to use the parallel indexing technique, generally used to monitor the vessel's progress in confined waters, to advantage. At the time of the investigation, training standards for ECDIS were being developed. Training received by the ship's navigation personnel was an overview of the ECDIS. Further, only one of the certificated officers on board (the chief officer, who was not on the bridge) had acquired an acceptable level of ECS proficiency. The bridge layout and the navigation network system were conducive to good BRM practices. IBS fosters a close working relationship and teamwork. It also improves efficiency and coordination between all members of the bridge team, including the pilot. However, until all team members have acquired sufficient knowledge and experience, the full benefit of a network system cannot be achieved. BRM training is now offered to crews and pilots, but it is essential that new technology form an integral part of such training, for pilots or for ships' navigation officers. 2.4 Vessel Manoeuvrability In recent years, a number of cruise liners were built with high manoeuvrability. The NorwegianSky is no exception. The turning manoeuvre off Cap Trinit, using small angles of helm, gave the pilot an opportunity to appraise the exceptional steering characteristics of this vessel. Although the NorwegianSky is considered highly manoeuvrable, it generates a substantial swept path when it turns. The greater the speed or helm angle, the greater the swept path. This non-traditional ship-handling characteristic is, in part, attributable to the number of rudders and the special design of the articulated flap rudder. As a precautionary measure, the pilots were warned verbally by the navigation personnel against the use of excessive helm. At 35 of helm, propeller thrust is diverted laterally, thereby creating an athwartships thrust similar to a thruster. This attribute may be very useful when manoeuvring in harbours but hazardous once the vessel has left its berth and proceeded down the river. When under way in a restricted waterway, there is no defence mechanism in place to prevent the application of excessive helm and no audio alarm to warn the navigator of excessive helm use, nor are there secondary measures (such as a warning placard or a cautionary note in the Deck Procedures Manual or pilot card). 2.5 Pilot Planning 2.5.1 Ship Handling The pilot deemed the vessel to have the fastest rate of turn he had ever witnessed. This rate might have influenced the pilot to place greater emphasis on accomplishing the turn using helm and to downplay the sweep/thrust effect. This emphasis is reflected in the pilot insisting on hard-a-port helm. The pilot had attended a ship-handling training centre for experienced pilots on two occasions, but the simulation courses attended did not include practice with a model ship equipped with a rudder fitted with a flap. Training fosters familiarity with procedures, reduces the time required to analyze emergency situations, and improves the coordination required to take evasive action. Although the pilot received an explanation of the vessel's ship-handling characteristics, his experience with the NorwegianSky was limited to the duration of his assignment. On conventional vessels, hard-over helm is used to derive maximum turning effect. Because the pilot was not accustomed to handling vessels fitted with flap rudders, the sweep/thrust effect of hard-over helm might not have been a predominant factor in the pilot's consideration. Under pressure to conduct the emergency manoeuvre, the pilot reverted to ordering hard-over helm. In 1996, the training facility used by the pilots of the Corporation added a model ship equipped with a flap rudder to its fleet to simulate vessels, such as the NorwegianSky. Given that safe handling of a vessel in emergency situations depends on the pilot's ability to respond, it is essential that simulation training reflect as much realism as possible, such as the visual environment and the characteristics of vessels they are required to handle. To mitigate this void in training, some pilotage authorities provide hands-on training, in a non-threatening environment, to help pilots that are required to handle such vessels better appreciate special ship-handling characteristics. 2.5.2 Dual Active Duty and Safety Statistics reveal that pilots are seldom required to conduct large passenger vessels. The requirement to extend whale-watching is even less frequent. Given that whale-watching is not always carried out in the same zone of the marine park and under the same conditions, preparation of a detailed voyage plan to turn these large vessels around in a predetermined area is not practical. Consequently, turning a vessel around in restricted waters, such as the marine park, must be planned at short notice and executed with precision. A pilot has to consider a number of factors to minimize risks before undertaking special manoeuvres near shoal waters. Because a detailed, pre-determined plan is not practical, good seamanship practices would dictate that a list of manoeuvring considerations should form part of a pilot's general passage plan for the area. This list would facilitate decision making and help in the development of specific plans at short notice. The potential risk of an accident for vessels engaged in whale-watching in restricted waters is higher than for vessels making normal transits of the area. The practice of two pilots sharing the workload and their expertise in restricted waterways can mitigate the risk by early recognition of danger. In this instance, the request to conduct an additional turn was not fully considered. Workload sharing by the second pilot would have permitted the bridge team to better assess the risk and to maintain situational awareness. Input from the second pilot would have presented the bridge team an opportunity to consider other appropriate measures: initially prior to commencing the turn and subsequently, as the turn progressed. Such an approach is consistent with the philosophy of using a team approach to eliminate single-point failure. In the event that an emergency situation develops, their combined expertise may help extricate the vessel from a dangerous situation. Nevertheless, the two pilots alternated shifts such that only one pilot was on duty at a time while the vessel was carrying out manoeuvres in the vicinity of the banks. This effectively negated the benefits associated with the carriage requirement for two pilots. Currently, there are no guidelines to help pilots determine when two pilots should be on duty. This permits pilots to use various criteria that need not necessarily take into consideration all elements essential to assess risk as reflected in this occurrence. The provision of guidelines will help ensure: a level of service appropriate to the assessed risk; uniform application of the two-pilot carriage requirement to meet the safety objective of the Laurentian Pilotage Regulationswhich recognize the need to eliminate single-point failure. In essence, such a operational system will help ensure that: pilots have identified safe parameters before operations involving higher-than-normal risk are undertaken; and that additional risks associated with the dynamic nature of pilotage can be identified in a timely manner to permit appropriate response to mitigate these risks. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors The manoeuvre to turn the vessel around to prolong whale-watching was improvised and not part of the vessel's voyage plan. This change from routine was not effectively planned or managed. The bridge team did not optimize the use of navigation equipment at their disposal to determine the approach limit to the banks to avert grounding. The pilot did not accept advice from the master, who was knowledgeable in the vessel's manoeuvring characteristics. As a result, the vessel's stern moved rapidly toward the banks (experienced sweep/thrust). The master did not countermand the pilot's order of hard-a-port helm. 3.2 Findings as to Risk Formalized training in an integrated bridge system environment is not mandatory. As a result, bridge teams may not make optimal use of the system. Because bridge resource management training varies among institutions around the world, with pilots and ships' officers often trained separately, the dynamics or interaction in the relationship between pilots and ships' officers can break down during emergency situations. Less-than-complete communication by the bridge team members resulted in navigation decisions based on scanty or incomplete information and increased risk of accidents. Carriage of an electronic chart display and information system is not mandatory on board vessels. As such, the quality and accessibility of training is inconsistent. As a result, a bridge team may not effectively make use of this situational awareness tool. There was no mechanism (physical or other), audio alarm, or secondary measure (such as a warning placard) to prevent or warn against the application of hard-over helm. The current practice of having one pilot on duty on vessels where two pilots are warranted and available, effectively negates the safety benefit of a team approach to eliminate single-point failure. The training facility used by the pilots of the Corporation des pilotes du bas Saint-Laurent did not provide, at the time the pilot undertook his training, models ships simulating non-traditional ship-handling characteristics, such as those produced by the NorwegianSky's articulated flap rudders. The pilot had not received hands-on training on similar vessels in a non-threatening environment, which could have lead to a better appreciation of non-traditional ship-handling characteristics. 3.3 Other Findings It took 21minutes for 787crew members to muster 1923passengers and prepare 16lifeboats. The prompt and efficient response to the exposed risk can be attributed, in part, to the training and the safety culture put in place by Norwegian Cruise Line. Contingency measures for the major search-and-rescue operation proved well organized. 4.0 Safety Action 4.1 Action Taken 4.1.1 Review of the Pilotage Issues In 1999, a Review Panel of the Canadian Transportation Agency (CTA) made a number of recommendations to the Minister of Transport on outstanding pilotage issues. With respect to double pilotage, the Review panel recommended that the Laurentian Pilotage Authority (LPA) be required to carry out a risk-based assessment by mid-2001. Further, they recommended the LPA be required to report the results of the risk-based assessment to the Minister of Transport and make the necessary regulatory amendments. The Corporation des pilotes du bas Saint-Laurent forwarded a report/study on double pilotage to the LPA to be used as a reference document in risk-based analysis. Transport Canada has recently made funding available to conduct the risk analysis recommended by the CTA. 4.1.2 Canadian Coast Guard The Rescue, Safety and Environmental Response Division of the Canadian Coast Guard's (CCG) Marine Programs Branch has initiated a public awareness program addressed to all waterfront townships in the Laurentian region. The program consists of informing local authorities that search and rescue (SAR) will require their immediate support when a passenger vessel is disabled and requires passengers to disembark. The CCG contingency plan was revised to: improve liaison between the public and waterfront township authorities; centralize the command centre; redefine parameters for passengers evacuation to facilitate crowd control and passenger mobility; develop a media strategy to cope with an evacuation operation; and improve the means of communication with a vessel requiring assistance to be able to react readily to unforeseen events. 4.1.3 Norwegian Cruise Line Norwegian Cruise Line developed and implemented a comprehensive set of bridge procedures which are part of the company's Safety and Environmental Management System. The procedures are compiled in the Navigation Standards Manual address shipboard navigational operations and provide guidance, directives and recommendations to the bridge team. The following is a brief description of the safety issues addressed in this report and dealt with by the company further to the occurrence : This report concludes the TSB's investigation into this occurrence. Consequently, the Board authorized the release of this report on 19 August 2003.